Advice to the Profession: Uninsured Services

Some physician services are not covered by the Ontario Health Insurance Plan (OHIP). These services are often referred to as “uninsured services” and include services such as prescription refills and medical advice over the phone, sick notes for work, the copy and transfer of medical records, immunization for the sole purpose of travel, the completion of insurance and/or medical forms, and a number of medical procedures.

As payment for these services is not subject to the same level of external oversight that is in place for insured services, patients may be particularly vulnerable when paying privately for uninsured services and may be particularly reliant on the honesty and integrity of physicians to ensure that their needs and interests are being put first.

The College’s Uninsured Services: Billing and Block Fees policy sets out expectations for physicians when billing for uninsured services regardless of practice area or specialty or the types of uninsured services being provided. This advice document is intended to help physicians interpret and understand these expectations to ensure they are effectively discharged.

What services can physicians bill for?

Physicians are not permitted to charge for the provision of insured services, including the constituent elements of an insured service. Examples of constituent elements of insured services include the referral of a patient to a specialist, the administrative processing for a new patient being accepted into a practice, and making arrangements for an appointment.¹

However, not all physician services are covered by OHIP and physicians are entitled to charge patients or third parties directly for the provision of these uninsured services, unless the government has otherwise agreed to pay them for these services (for example, telemedicine that is provided through the Ontario Telemedicine Network).

For more information regarding which services are insured and which are uninsured, physicians can review Section 24 of the General Regulation enacted under the Health Insurance Act, the Schedule of Benefits, and the Ontario Medical Association’s Physician’s Guide to Uninsured Services (“the OMA Guide”).

What should physicians charge for uninsured services?

The policy requires that fees for uninsured services, including block fees and fees for appointments that are missed or cancelled without proper notice, be reasonable.

When setting fees, physicians will need to consider both the nature of the service being provided (e.g., sick notes vs. a medical procedure) and their professional costs (e.g., the time involved, whether other staff are involved, etc.). It’s important for physicians to be aware that it is an act of professional misconduct to charge a fee that is excessive in relation to the services provided.

The Ontario Medical Association publishes an annual Physician’s Guide to Uninsured Services which can help physicians set their fees and some specialty associations set out recommended fees as well.

Physicians also need to know that in some instances fees will be set out in law or by order of the Information and Privacy Commissioner.²

Finally, physicians may choose to charge patients who miss an appointment or cancel without the required notice, recognizing both the lost opportunity costs to other patients as well as the costs to themselves (e.g., lost opportunity to bill OHIP, or actual costs incurred by the physician). In setting these fees, physicians must consider a variety of factors including what would be reasonable cost recovery for themselves and what would act as a reasonable deterrent for patients.

Why do physicians need to consider their patients ability to pay?

Some patients may experience great difficulty paying for the health care services that they need. Recognition of this fact is embedded in the Canadian Medical Association’s Code of Ethics, which states that physicians will need to consider not just the nature of the service being provided, but also the patient’s ability to pay when setting their professional fees.³ The College’s expectation is consistent with this position.

This does not mean, however, that physicians are required to provide uninsured services for free. Rather, the policy requires physicians to give consideration to whether it would be appropriate to reduce, waive, or allow for flexibility based on compassionate grounds. Whether it is appropriate to adjust fees on compassionate grounds will depend on a variety of factors including the nature of the service being provided and the specific financial circumstances of the patient.

For example, physicians may weigh these factors differently depending on whether they are providing elective cosmetic procedures or employer required sick notes, or whether a patient is receiving disability support payments or is gainfully employed.

The policy recognizes that physicians are entitled to charge for the uninsured services they provide, but aims to strike a balance between this entitlement and the reality that some patients will have real difficulty paying for services that they need.

How can physicians assess a patient’s ability to pay?

In some practice settings, physicians may naturally become aware of information relevant to a patient’s ability to pay during the course of the physician-patient relationship (e.g., occupation, challenges faced, etc.).

Physicians can also invite patients to self-identify as being in financial need if they are at all concerned about being able to pay a fee. This can be done by the physician, through their office staff, or even in any written notice about fees for uninsured services. With this information in hand, physicians can use their professional judgment to determine if it would be appropriate under the circumstances to reduce, waive, or allow for flexibility with respect to the fee.

What should be kept in mind when insured and uninsured services are bundled or offered as alternatives to one another?

Physicians sometimes propose or provide insured and uninsured service together or offer uninsured services as an alternative or adjunct to insured services. These situations are ripe for confusion and patients are particularly reliant on the honesty and integrity of their physicians to ensure their needs and interests are being put first, and that they have clear information about their clinical options and any corresponding fees.

As such, clear communication is essential to these discussions. In these situations physicians must clearly communicate which services or elements of a service are associated with a fee and which are not and must describe the patient’s options in a clear and impartial manner.

Physicians also have to be particularly careful to ensure that if their practice structure leads to different wait times for the insured and uninsured services they provide or when insured services are bundled with uninsured services, that doing so complies with the Commitment to the Future of Medicare Act, 2004 (CFMA). The CFMA prohibits physicians from charging or accepting payment or benefit in exchange for preferential access to insured services.

Physicians are encouraged to obtain independent legal advice about their practice structure if they are at all unsure about whether it complies with the CFMA.

What happens if a patient accumulates a number of outstanding fees?

Physicians are entitled to seek payment for the uninsured services they provide and can take action to collect any fees that are owed to them. This could include, for example, using office staff to remind patients of any outstanding fees or hiring a collection agency. However, physicians must always pursue payment in a professional manner and must consider whether it would be appropriate to reduce, waive, or allow for flexibility in the amount owed based on compassionate grounds.

Importantly, failure to pay outstanding fees cannot be used as grounds for denying a patient access to insured services. Physicians can, however, use their professional judgment to determine whether to withhold access to additional uninsured services when the patient has an outstanding balance, giving consideration to both the patient’s need for those services and their ability to pay the outstanding balance.

In circumstances where patients have refused to pay an outstanding fee, or have accumulated a number of unpaid fees without reasonable justification for non-payment (such as evidence of financial hardship), if physicians are considering ending the physician-patient relationship they must do so in compliance with the expectations set out in the College’s Ending the Physician-Patient Relationship policy.

What are the benefits of a block fee and when can physicians offer them?

A block fee may be a more convenient and/or economical way for patients to pay for uninsured services, and for physicians to administer fees for these services. Generally speaking, a block fee allows patients to pay a one-time flat fee that covers them for any uninsured services they need throughout a given time period. This also simplifies the processing of fees for physicians as they just need to collect one fee. Physicians are not required to offer a block fee, but may do so if they wish.

However, a block fee may not be appropriate for all practice settings where uninsured services are provided. Whether a block fee is appropriate will depend on a variety of factors including, but not necessarily limited to, the nature of the physician’s practice and their specialty. For example, if the anticipated duration of care is a single visit, it is unlikely that a block fee would be necessary. Additionally, if it is known precisely how many uninsured services a patient will need, this would not align with the definition of a block fee as set out in the CFMA which states that at the time of payment it is not possible to know how many services will be needed.

Patients may sometimes be confused about what a block fee is and what it means for their care. For these reasons, the policy sets out a number of expectations for physicians who choose to offer their patients this option, all aiming to help patients make fully informed decisions about how they would like to pay for uninsured services.

Endnotes

^1. For a complete list of the common and specific elements of insured services that are considered to be constituent elements of the insured medical services covered by OHIP, see the preamble to the Schedule of Benefits: Physicians Services under the Health Insurance Act.

^2. See Section 37(5) of the Workplace Safety and Insurance Act, 1997, S.O. 1997 c.16, Sched. A and Information and Privacy Commissioner orders HO-009 and HO-14. See as well the College’s Medical Records Management and Third Party Medical Reports policies for further information.

^3. Canadian Medical Association’s Code of Ethics #16: “In determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.”